Healthcare providers, such as pharmacies, physicians, and/or hospitals, often generate healthcare claims or healthcare claim transactions that are communicated to appropriate claims processors or payors, such as insurance providers or government payors. In the majority of circumstances, a Medicare program is utilized as a payor of last resort after other available payors, such as commercial insurance programs, have been billed. However, certain specialty products or services, such as immunosuppressant drugs, may be eligible for certain Medicare coverage without first billing other available payors. More specifically, Medicare Part B plans may be billed first for patients that are eligible for Medicare Part B coverage.
Healthcare providers are often unaware of a patient's Medicare Part B eligibility. Additionally, patients may not be aware of their Medicare Part B eligibility, much less the products and services that are covered by Medicare Part B. As a result, commercial insurance plans or other commercial payors are often billed first for products or services that are eligible for Medicare Part B coverage. As a result, commercial payors may generate charge-backs at a later point in time for certain products and/or services. It is often difficult for healthcare providers to recoup funds for these incorrectly billed healthcare claim transactions. Accordingly, the charge-backs may lead to substantial lost revenue on the part of the healthcare providers.
Therefore, a need exists for systems and methods for evaluating healthcare claim transactions for Medicare eligibility.